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Understanding Infertility Ectopic Pregnancy

Ectopic Pregnancy Treatment

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Ectopic pregnancy literally means “out of place” pregnancy; it occurs when a fertilized egg implants at a site outside the uterine cavity.

95% of all ectopic pregnancy cases implant within the fallopian tube. Non tubal implantation sites are uncommon and may involve the ovary, cervix, C-Section scar or abdominal cavity.

All normal pregnancies begin within the fallopian tube when an egg is fertilized by sperm. The fertilized egg remains in the tube for 3-5 days and is transported into the uterus by contractions of the tube and by the sweeping movement of fine, hair-like cells (cilia) lining the tube. Any condition causing inflammation of the tube can damage the cilia lining the fallopian tube. This can compromise the process of transporting the embryo through the tube, resulting in implantation of the embryo outside the uterine cavity.

Ectopic, or tubal, pregnancy cannot develop into a successful pregnancy and can pose a significant risk to the mother’s health if not detected and treated promptly. On average, ectopic pregnancies are estimated to occur in about 1-2% of all pregnancies.

Risks factors associated with tubal pregnancy:
  • Previous pelvic infection – 4 fold increased risk
  • Endometriosis
  • History of previous tubal pregnancy
  • Previous tubal surgery or reversal of tubal ligation
  • Infertility, ovulation induction therapy using Clomiphene or injectable Gonadotropins
  • IVF is associated with a 2-4% incidence of ectopic pregnancy
  • Older age (over age 35) – 3 to 4 fold increase in the risk of tubal pregnancy as compared with women younger than age 25
  • Smoking – 2-4 fold that of nonsmokers
  • Intrauterine device (IUD) – more so with those containing progesterone
Symptoms

Ectopic pregnancy should be considered in any woman of reproductive age, presenting with pain, abnormal bleeding or irregular periods.

Beta HCG level

A simple blood pregnancy test (beta HCG and progesterone levels) early in pregnancy can be utilized to monitor the pregnancy.

Ultrasound

When the beta HCG reaches a level of 1500 miu/ml, an ultrasound can determine whether the pregnancy is located within the uterus or outside.

In infertility practices, tubal pregnancies are diagnosed relatively early because patients are closely monitored and are tested for the pregnancy marker – the Beta HCG (Human Chorionic Gonadotropin) level – when their menstrual period is expected. Once a positive pregnancy test is detected, the HCG level is checked every 2-3 days. It normally doubles approximately every 2 days, so lower than expected levels may indicate an ectopic pregnancy or an impending miscarriage.

When the beta HCG reaches a level of 3000 miu/ml, a pregnancy sac should be detected by vaginal ultrasound, and failure to see the pregnancy inside the uterus is presumptive of an ectopic pregnancy.

In rare cases, especially when the woman undergoes IVF, a tubal pregnancy may coexist with a normal uterine pregnancy (heterotopic pregnancy). 

Early diagnosis by ultrasound and assessment of the woman’s condition is critical in determining the appropriate care.

The goal of treatment for ectopic pregnancy is to preserve the woman’s fertility and to treat only the tubal pregnancy. There are 2 treatment options:

  • Medical treatment
  • Surgical treatment

Occasionally, the ectopic pregnancy will simply deteriorate spontaneously (much like a miscarriage) and will be absorbed by the body. However, the tube may also rupture if not treated in time.

Medical treatment of ectopic pregnancy involves injections of a drug called Methotrexate to stop the growth of the embryo. 

You are a good candidate for the treatment if:
  • The ectopic is discovered early before it ruptures.
  • Beta HCG hormone level is less than 15,000.
  • The size of the pregnancy in the tube is less than 4 cm.
  • No heartbeat is detected by ultrasound.
  • You have no pain.

Once you receive your Methotrexate injection, you will be closely monitored with several pregnancy hormone levels (HCG) to make sure the HCG begins to drop. You will then undergo weekly testing for HCG level until your HCG level decreases to 0 indicating that the problem has been resolved. If after a week, your HCG hormone level remains high, you will be given another injection of Methotrexate while continuing to monitor the HCG levels. If the HCG hormone level continues to rise, laparoscopic surgery will be necessary to remove the ectopic pregnancy

Laparoscopic surgery to remove the ectopic pregnancy while preserving the tube depends on the site of implantation within the tube and on whether or not the pregnancy has ruptured.

Laparoscopic surgery may be indicated if:
  • You experience significant pain.
  • The tubal pregnancy is ruptured and is bleeding into the abdominal cavity.
  • The tubal pregnancy is too large (greater than 4 cm).
  • A heartbeat is seen within the pregnancy sac.
  • The beta HCG level is very high.
  • This is a recurrent ectopic pregnancy in the same tube.
  • You were given Methotrexate but the tubal pregnancy is continuing to grow.
How is laparoscopic surgery for ectopic pregnancy performed?

Depending on the extent of the ectopic pregnancy and the condition of the fallopian tube, different surgical options are considered:

  • Salpingectomy: If the fallopian tube is severely damaged or ruptured, the surgeon may need to remove it. This is done by cutting and sealing the affected portion of the tube.
  • Salpingostomy: If the tube is minimally damaged and can be preserved, the surgeon may make a small incision in the tube to remove the ectopic pregnancy while leaving the tube intact.
Monitoring the Treatment

After surgical or medical treatment of the ectopic, your doctor will order a weekly beta HCG level for several weeks until the Beta-HCG hormone level is negative, indicating that the problem is resolved.

If your blood type is Rh negative you will be given Rhogam to prevent sensitization of your immune system in subsequent pregnancies.

  • Ruptured ectopic is a medical emergency, and if unrecognized, may result in death.
  • Ectopic pregnancies may cause other serious complications, such as bleeding, infection and infertility.
  • There is a risk that your next pregnancy may be complicated by another tubal pregnancy.

You may experience more difficulty conceiving. Once you have had an ectopic pregnancy, you have about 15-20% chance of having another. Contact your doctor immediately if you become pregnant again, so that he/she can schedule tests and an early ultrasound to make sure your pregnancy is implanted inside the uterus.

Infertility patients with a history of tubal pregnancy should also consider In Vitro Fertilization (IVF).